Primary Focal Hyperhidrosis: Disease Characteristics and Functional Impairment

Iontophoresis Improves the Impact on the Quality of Life of Children with Primary Hyperhidrosis-A Prospective Study and a Short Review

BACKGROUND

Primary hyperhidrosis (PH) is a somatic and idiopathic pediatric skin disease. The eccrine glands are tiny and very numerous, with approximately 3 million distributed throughout the skin. There is no commonly accepted amount of sweating to define hyperhidrosis, but people with this disease suffer real limitations integrating into society, which can be quantified through quality of life measurement scales. We want to draw attention to this disease and its impact on children's quality of life because it is significant and there are no studies conducted on groups consisting solely of children.

METHODS

There are various quality of life evaluation questionnaires for hyperhidrosis. We studied 103 children with hyperhidrosis by monitoring their sweat severity and its impact on quality of life, using the Hyperhidrosis Disease Severity Scale. We compared the scale results before and after 10 days of iontophoresis. This study includes only children under 18 years old, treated with iontophoresis.

RESULTS

The average age of the group is 11.84 ± 2.89 years. Treatment success is recorded in 68 (66.02%) children, but a change in the score is recorded in 74 (71.84%) children. The average HDSS score at T0 is 2.95 ± 0.70, compared to the HDSS score at T1 of 1.92 ± 0.86.

CONCLUSIONS

Hyperhidrosis has a negative impact on daily life, especially self-esteem, occupational productivity, emotional well-being, and interpersonal relationships. Iontophoresis is a safe and effective treatment method that reduces the severity of hyperhidrosis and increases the quality of life.

Internalized stigma, disease severity, quality of life, anxiety and depression in axillary hyperhidrosis

BACKGROUND

Axillary hyperhidrosis (AH) is characterized by excessive underarm sweating. It is a chronic autonomic disorder that can lead to social embarrassment, impaired quality of life (QoL), anxiety and depression. Internalized stigma (IS), defined as the acceptance of negative societal attitudes and stereotypes about an individual's illness, has not been previously studied in AH. The aim of this study was to evaluate the level of IS in patients with AH and the relationships between IS, disease severity, quality of life, anxiety, and depression.

PATIENTS AND METHODS

One hundred and four patients with AH were included in the study. Demographic and clinical characteristics of the patients were recorded. The Hyperhidrosis Disease Severity Scale (HDSS) was used to define disease severity. Assessment was made using the Internalized Stigma Scale (ISS) (between 29 and 116, the higher the score the greater the stigma), Hospital Anxiety and Depression Scale (HADS) and Dermatology Life Quality Index (DLQI).

RESULTS

The mean age of the patients was 34.1 ± 10.9 years. The HDSS grade was mostly moderate to severe. The mean ISS score was 57.5 ± 6.5. Median HADS scores were 7 [interquartile range (IQR) 2-12] and 5 [IQR 2-10], respectively. HADS scores ≥ 8 were observed respectively in 39.4% and 8.7% of patients. The median DLQI score was 14 [IQR 4-24]. A DLQI score ≥ 11 was observed in 75% of patients. Significant correlation was found between ISS score and HDSS (r = 0.445, p < 0.001), HADS-A (r = 0.455, p < 0.001), DLQI (r = 0.478, p < 0.001) scores and symptom duration (r = 0.207, p = 0.035). The relationship between ISS and HADS depression scores was not statistically significant.

CONCLUSION

IS is common in patients with AH. Disease severity, symptom duration and anxiety increased IS. Patient's quality of life is reduced in AH.

The reliability and validity of a developed anxiety scale specific to primary focal hyperhidrosis symptoms

BACKGROUND

Patients with primary focal hyperhidrosis (hyperhidrosis) are known to have higher levels of anxiety induced by sweating than those who do not. However, in hyperhidrosis, no scale has been developed to measure anxiety specific to hyperhidrosis symptoms. Therefore, this study aimed to develop an anxiety scale specific to hyperhidrosis symptoms (ASSHS) and to verify its reliability and validity.

METHODS

Based on previous studies on hyperhidrosis and a preliminary survey conducted with 26 university students who met the diagnostic criteria for hyperhidrosis, 40 items that adequately reflected anxiety specific to hyperhidrosis symptoms were obtained. A survey was done to examine the internal consistency and validity of the our developed ASSHS. In total, 1,207 participants (680 male and 527 female; mean age ± standard deviation 18.7 ± 0.9 years) were included. A second survey (re-survey) was conducted three weeks later to verify the reliability. It included 201 participants (85 male and 116 female; mean age ± standard deviation 18.6 ± 0.7 years). The survey items included (1) the diagnostic criteria for hyperhidrosis, (2) our anxiety scale developed for primary focal hyperhidrosis symptoms (ASSHS), (3) Hyperhidrosis Disease Severity Scale (HDSS), (4) State-Trait Anxiety Inventory (STAI), (5) Hospital Anxiety and Depression Scale (HADS), (6) Dermatology Life Quality Index (DLQI), and (7) presence of anxiety induced by sweating.

RESULTS

The results of the factor analysis revealed 10 items with one factor, "anxiety specific to hyperhidrosis symptoms." The alpha coefficient of the ASSHS was α = 0.94. The correlation coefficient between the scores at re-test was r = 0.75. A moderate positive correlation was found between the ASSHS, HDSS (r = 0.53), and anxiety induced by sweating (r = 0.47) (all p < 0.001). Additionally, participants with hyperhidrosis symptoms had significantly higher ASSHS scores than did those without hyperhidrosis symptoms (p < 0.001). Those with mild/moderate hyperhidrosis and those with severe hyperhidrosis had significantly higher the ASSHS scores than did those without hyperhidrosis (p < 0.001).

CONCLUSIONS

This scale has sufficient reliability and validity as an instrument to measure anxiety specific to hyperhidrosis symptoms.

Primary Hyperhidrosis in Children-A Retrospective Study and a Short Review

Primary hyperhidrosis (PH) is a relatively common chronic disorder, characterized by significant and uncontrollable sweating. The predominant areas of occurrence are hands, feet, head and armpits, and it affects both men and women equally, with a false impression of increased prevalence in women. This study aims to determine the incidence of cases of hyperhidrosis, the gender of the patients and the environment of origin and to identify the most affected age groups and the distribution of hyperhidrosis, as well as creating a curve of cases within the time interval studied and their comparison with those in the specialized literature.

Impostor phenomenon is a common feature among individuals with primary hyperhidrosis

Background

Primary hyperhidrosis consists of excessive focal sweating. Affected individuals camouflage the sweating on their body, avoiding stigmatisation. Hence, misrepresentation in social interactions is a common feature in patients with hyperhidrosis. The aim of this study was to investigate impostor phenomenon, perfectionism, self-compassion, stress and anxiety among individuals with primary hyperhidrosis.

Methods

A cross-sectional study was conducted at our clinic among 100 participants with axillary and palmar primary hyperhidrosis. The questionnaire contained a hyperhidrosis part and Perceived Stress Scale-4, Generalised Anxiety Disorder Scale-2, Clinical Perfectionism Questionnaire-6, Self-Compassion Scale Short form and Clance Impostor Phenomenon Scale. Descriptive statistics was used for analyses of categorical variables. As data were normally distributed independent t-test and one-way analysis of variance with post hoc Tukey test were used to compare the mean values for the questionnaires with other variables. Pearson's correlation was used, and a forward multiple linear regression model was performed to predict presence of impostor phenomenon with gender, age and other scales in this study.

Results

Impostor phenomenon occurred in almost half of our patients (48%) with hyperhidrosis. While feelings of impostor phenomenon were more common in women, there was no difference between gender regarding its intensity levels (p = 0.07). In addition, we found a significant (p < 0.001) negative correlation between impostor phenomenon and self-compassion, while feelings of impostoer phenomenon increased with stress, anxiety and perfectionism (p < 0.001).

Conclusions

Feelings of impostor phenomenon was found in 48% of individuals with hyperhidrosis which indicates that it is a common feature in this patient group. Future research is warranted regarding the prevalence of impostor phenomenon in hyperhidrosis and other medical conditions, among men and women, seeking medical healthcare. Psychological interventions in hyperhidrosis may be beneficial both for the individual and in public health, by facilitating management of patients' daily lives and saving considerable resources in healthcare regarding pharmacological interventions and medical consultations.

Longitudinal Assessment of Facial Hyperhidrosis Management: Evaluating the Utility and Quality of Life Improvements following Botulinum Toxin Injection

Facial hyperhidrosis is a debilitating condition that can severely impact the quality of life. This study aimed to assess the long-term utility of Botulinum toxin type A therapy (BTA) for facial hyperhidrosis and its impact on quality of life over a one-year period. Conducted at the Pius Brinzeu Clinical Emergency Hospital in Timisoara, Romania, this longitudinal observational study involved 77 adult patients with primary facial hyperhidrosis. Participants received two sessions of Botulinum toxin injections (50 U IncoBTX-A each) and were evaluated at baseline, 6 months, and 12 months using the Hyperhidrosis Disease Severity Scale (HDSS), WHOQOL-BREF, Dermatology Life Quality Index (DLQI), and a bespoke survey. The study demonstrated significant reductions in HDSS scores from 3.6 ± 0.5 to 1.2 ± 0.8 post-treatment, sustained at 1.3 ± 0.6 at 12 months (p-value < 0.001). DLQI scores markedly decreased from 24.8 ± 4.2 to 6.2 ± 2.1 post-treatment, stabilizing at 6.5 ± 2.5 at 12 months (p-value < 0.001). Sweat production significantly dropped from 0.75 g ± 0.15 to 0.18 g ± 0.07 per 15 min (p-value < 0.001). WHOQOL-BREF scores improved notably in the mental domain from 66.7 ± 6.1 to 70.8 ± 5.2 at 12 months (p-value < 0.001), with physical and social domains also showing significant improvements. Correlation analysis revealed strong negative correlations between DLQI total score and HDSS (rho = -0.72, p-value < 0.001) and sweat production (rho = -0.68, p-value < 0.001). Regression analysis indicated significant predictors for DLQI total score, including HDSS (B Coefficient = -3.8, p-value < 0.001) and sweat production (B Coefficient = -2.2, p-value < 0.001). BTA therapy significantly improved the quality of life in facial hyperhidrosis patients, with lasting effects on symptom severity, sweat production, and quality of life domains. The correlation and regression analyses further substantiated the treatment's impact on both physical and psychological aspects. These findings advocate Botulinum toxin as a viable long-term treatment for facial hyperhidrosis.

Reconstituted and frozen botulinum toxin A is as effective and safe as fresh for treating axillary hyperhidrosis: A retrospective study

The use of reconstituted and frozen left-over botulinum toxin A, for treatment of patients with axillary hyperhidrosis seems to be common practice in healthcare. Thus, the objective of this study was to investigate the efficacy and safety of frozen and thawed versus fresh reconstituted abobotulinum toxin (Dysport®) and onabotulinum toxin (Botox®) in the treatment of axillary hyperhidrosis. A retrospective study was conducted analysing efficacy and data from pre- and 24 weeks post-treatment questionnaires together with medical records of individuals with moderate to severe axillary hyperhidrosis. The patients had received fresh prepared botulinum toxin A in their right axilla while frozen and thawed botulinum toxin A had been administered in their left axilla. Treatment was conducted at our Hyperhidrosis Clinic, Umeå University Hospital, Sweden 2019-2021. Pre- and post-treatment questionnaires from 106 patients were analysed. The patients were 18 to 55 years old, with a mean age of 30.7 ± 9.9 years. No significant differences in patient-reported variables, Hyperhidrosis Disease Severity Scale and VAS 10-point scale, were found between the different preparations (frozen compared to fresh) for abobotulinum toxin and onabotulinum toxin, before treatment and at 6 months follow-up. Multivariable regression analysis resulted in no significant difference regarding side-effects between the preparations or brands of botulinum toxin. The findings of this study support our clinical experience that both abobotulinum toxin and onabotulinum toxin, reconstituted, frozen and thawed, seem to be as effective and safe as fresh prepared botulinum toxin when treating axillary hyperhidrosis. Our findings indicate that left-over preparations of abo- and onabotulinum toxins, stored and frozen for up to 6 months, is a cost-and time-effective way of handling botulinum toxin for treatment of axillary hyperhidrosis.

Long-term evaluation of the safety and efficacy of a novel 20% oxybutynin hydrochloride lotion for primary palmar hyperhidrosis: An open-label extension study

The long-term safety and efficacy of 52-week application of oxybutynin hydrochloride 20% lotion (20% OL) for the treatment of primary palmar hyperhidrosis (PPHH) in Japanese patients aged ≥12 years were evaluated in an open-label extension (OLE) of a 4-week, randomized, double-blind (DB) study. The OLE included 114 patients who completed the DB study and wished to continue treatment and 12 new patients. In the safety analysis population (125 patients), the incidence of adverse events (AEs) and adverse drug reactions (ADRs) was 79.2% and 36.0%, respectively. Serious AEs were observed in two patients but were considered unrelated to the investigational drug. The incidence of AEs that led to study discontinuation was 1.6%. The incidence of application site AEs and ADRs was 35.2% and 26.4%, respectively. The severity of most events was mild. The incidence of anticholinergic AEs related to dry mouth was 3.2% for thirst and 0.8% for dry throat. The long-term efficacy of 20% OL was confirmed by a long-lasting reduction in sweat volume and improvement in the Hyperhidrosis Disease Severity Scale and Dermatology Life Quality Index. This study has several limitations: First the results may include some bias because most of the participants were from the prior DB study; second, the results may not be generalizable because only a few participants were in the age group most susceptible to PPHH (i.e., < 15 years old); and third, the study did not obtain safety information from treatment for more than 52 weeks, so this information must be collected in clinical practice in the future. No reduced therapeutic effect was observed in patients with PPHH in this study after 52-week application of 20% OL. Also, few patients experienced serious AEs or AEs that led to study treatment discontinuation.

Therapeutic Effectiveness of Needle Injection Versus Needle-Free Jet Injector System for Botulinum Toxin Type A in Palmar Hyperhidrosis

BACKGROUND

The most important problem with local injections of botulinum toxin type A (BTX-A) in palmar hyperhidrosis is pain during the injections.

OBJECTIVES

We evaluated therapeutic effectiveness and pain of local injections of BTX-A using needle-free direct administration system.

METHODS

We performed BTX-A local injection therapy using a conventional injection needle in the left hand and a needle-free direct administration system in the right hand.

RESULTS

A reduction in the quantity of perspiration was observed 4 weeks after administration of both Needle and Needle-free BTX-A, and reduction was maintained throughout 28 weeks observation period. Both hyperhidrosis Disease Severity Scale scores and Dermatology Life Quality Index for hands treated with Needle BTX-A and hands treated with Needle-free BTX-A had decreased significantly by 4 weeks after treatment. Pain visual analog scale scores and the degree of pain were significantly lower in hands treated with Needle-free BTX-A than in hands treated with Needle BTX-A.

CONCLUSIONS

When the trigger of the pressurized needle-free injector device is activated, the gas powered driving pressure propels BTX-A through an orifice (0.13 mm) about four times narrower than a 30 G needle at very high speed. As most pain occurs during the needle prick itself, the advantage of a small orifice coupled with high-speed penetration of BTX-A through the pressurized device results in reduced pain during administration. The needle-free direct administration system administers the injectate under the skin without a visible needle.

Quality of life in individuals with primary hyperhidrosis: a systematic review and meta-analysis

PURPOSE

Hyperhidrosis can be a debilitating disease that leads to the deterioration of well-being. In this study, the objective was to compare the health-related quality of life (HRQOL) in individuals with and without hyperhidrosis by conducting a systematic review and meta-analysis.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Meta-analysis Of Observational Studies in Epidemiology checklist were employed. We systematically searched Cochrane Library, Embase and PubMed. Two authors independently assessed the literature and extracted the data. The risk of bias was assessed using the Newcastle-Ottawa Scale. A random-effects model was employed. The heterogeneity was determined using I2.

RESULTS

Eleven studies met the eligibility criteria comprising 4297 and 147,604 participants with and without hyperhidrosis, respectively. The risk of bias ranged from high quality to very high risk of bias. The individuals with hyperhidrosis had a higher Dermatology Life Quality Index (mean difference 8.53; 95% confidence interval 3.47, 13.58; p = 0.0009) and a lower mental component summary of the short form-12 or -36 (mean difference -6.15; 95% confidence interval -9.00, -3.30; p < 0.0001) than the control individuals. No difference was found for the physical component summary score of the short form-12 or -36 (mean difference -0.88; 95% confidence interval -1.88, 0.12; p = 0.085). Studies using patient-reported outcomes, not included in the meta-analysis, showed similar results.

CONCLUSION

Individuals with hyperhidrosis experience a reduced HRQOL that is clinically meaningful and leads to perceivable deteriorations in their well-being. The evidence shows a high degree of heterogeneity, which warrants additional studies.

A novel lotion formulation of 20% oxybutynin hydrochloride for the treatment of primary palmar hyperhidrosis: A randomized, placebo-controlled, double-blind, phase III study

BACKGROUND

No previous controlled studies have been specifically designed or adequately powered to show the efficacy of topical oxybutynin for palmar hyperhidrosis by using quantitative measures.

OBJECTIVE

To evaluate efficacy of 20% oxybutynin hydrochloride lotion (20% OL) in reducing palmar sweat volume in patients with primary palmar hyperhidrosis (PPHH).

METHODS

In a randomized controlled trial, Japanese patients with PPHH aged 12 years and older received either 20% OL (n = 144) or placebo (n = 140) on both palms once daily for 4 weeks. Palmar sweat volume was measured by the ventilated capsule method. For the primary outcome, response was defined as a reduction of sweat volume of at least 50% from baseline.

RESULTS

At week 4, the responder rate for sweat volume was significantly higher in the 20% OL arm than in the placebo arm (52.8% vs 24.3%, respectively; treatment difference, 28.5% [95% CI, 17.7% to 39.3%]; P < .001). No serious adverse events occurred, and no adverse events led to treatment discontinuation.

LIMITATIONS

The treatment period was only 4 weeks.

CONCLUSIONS

In patients with PPHH, 20% OL is superior to placebo in reducing palmar sweat volume.

Questionnaire-based epidemiological survey of primary focal hyperhidrosis and survey on current medical management of primary axillary hyperhidrosis in Japan

To obtain current epidemiological information on primary focal hyperhidrosis in Japan, a large epidemiological survey was conducted using a web-based questionnaire. The prevalence of primary focal hyperhidrosis was 10.0% and the site-specific prevalence was highest for primary axillary hyperhidrosis (5.9%). The proportion of respondents with primary focal hyperhidrosis who had consulted a physician was 4.6%, which was similar to the low prevalence reported previously in 2013 in Japan. A questionnaire survey for physicians and individuals with primary axillary hyperhidrosis on the current medical management of primary axillary hyperhidrosis showed that physicians recognized the existence of patients who were very worried about hyperhidrosis, but failed to provide active treatment. Regarding the information provided by patients to physicians at presentation, it was found that patients failed to provide sufficient information to the physicians about their worries in daily life. Among individuals who had sought medical care with primary axillary hyperhidrosis, 62.3% reported that they were not currently receiving treatment, highlighting a challenge to be addressed regarding continued treatment. Frequently chosen options leading to willingness to receive treatment were less expensive treatment and highly effective treatment as well as feeling free to consult a physician, suggesting a desire for an improved medical environment.

Association of primary focal hyperhidrosis with anxiety induced by sweating: A cross-sectional study of Japanese university students focusing on the severity of hyperhidrosis and site of sweating

Hyperhidrosis significantly reduces patients' quality of life, with many reporting feeling highly anxious. However, the relationship between hyperhidrosis and anxiety induced by sweating has not been examined in detail. The current study examined the relationship between: (1) the presence of hyperhidrosis symptoms, (2) hyperhidrosis severity, and (3) the sites of the most sweating and anxiety induced by sweating. A cross-sectional web-based survey was conducted among university students, and 1080 consenting participants (600 males and 480 females; mean age, 18.8 years) were included in the analysis. The survey items were: (1) diagnostic criteria for hyperhidrosis, (2) Hyperhidrosis Disease Severity Scale, (3) presence of anxiety induced by sweating, and (4) site of the most sweating. The results of multiple logistic regression analysis adjusted for sex and age showed that the odds ratio (OR) for anxiety induced by sweating was significantly higher in participants who screened positive for hyperhidrosis than in those who screened negative (OR, 9.72 [95% CI, 5.80-16.27]). The OR of anxiety induced by sweating was 7.11 (95% CI, 3.99-12.65) for mild/moderate hyperhidrosis and 23.46 (95% CI, 7.15-76.93) for severe hyperhidrosis, compared with those who screened negative for hyperhidrosis. Compared with those who screened negative for hyperhidrosis, the OR for anxiety induced by sweating in those with the palmar, plantar, axillary, and head/face as the site of the most sweating was 7.74 (95% CI, 3.91-15.33), 14.86 (95% CI, 1.83-120.58), 16.92 (95% CI, 5.95-48.14), and 5.38 (95% CI, 1.39-20.74), respectively. Our findings suggest that participants who screened positive for hyperhidrosis, mild/moderate or severe, are at a higher risk of anxiety induced by sweating than participants who screened negative for hyperhidrosis.

Hyperhidrosis: A Central Nervous Dysfunction of Sweat Secretion

Hyperhidrosis (HH) is a central nervous dysfunction characterized by abnormally increased sweating due to a central dysregulation of sweat secretion. HH significantly affects the quality of life of patients in their private, social and professional environments. Physiologically, sweating is a mechanism that regulates body temperature, but it may also be triggered by emotional or gustatory stimuli. There are two main types of sweat glands: eccrine and apocrine glands. The central nervous system controls sweat secretion through the release of neurotransmitters into the autonomous nervous system (ANS) that activate the sweat glands. The hypothalamus has two separate neuronal pathways, one for thermoregulation and one for emotions. HH may thus be due to either a neuronal dysfunction of ANS regulation leading to a hyperactivity of the sympathetic nervous system, or to abnormal central processing of emotions. Crucially, there is no dysfunction of the sweat glands themselves. Various pathogenic mechanisms have been proposed to be involved in pathological sweat secretion in HH, ranging from structural changes within the ANS to increased expression of aquaporin 5 and upregulation of activin A receptor type 1 in eccrine sweat glands. Although a genetic predisposition has been demonstrated, it remains unclear exactly which genes are involved. To identify new, potential therapeutic targets and to improve treatment options, a good understanding of the signaling pathways involved, the underlying mechanisms, and the genetic components is essential. In this review we discuss the various aspects of sweat physiology and function that are necessary to explain pathological sweating. Our aim is to raise awareness of the complexity of HH to promote a better understanding of the disorder.

The Impact of Hyperhidrosis on Quality of Life: A Review of the Literature

Hyperhidrosis is a condition of excessive sweating, which can have profound physical and mental effects. Hyperhidrosis is a significantly impactful and distressing illness that warrants equal attention as other more well-known dermatologic conditions. However, because of a lack of awareness among the public, stigma, and difficulty with access to treatments (due to cost or insurance coverage), patients are less likely to be diagnosed and treated. In hyperhidrosis, quality-of-life surveys can be useful for determining the magnitude of symptoms and to evaluate treatment outcomes. The purpose of this study was to conduct a narrative literature review to investigate the impact of hyperhidrosis on quality of life. A total of 49 articles investigating the impact of primary hyperhidrosis on quality of life were selected for the review. Hyperhidrosis is a potentially debilitating illness that affects multiple domains of patients' lives including their psychological, physical, and social functioning. Despite the significant impacts, patients with hyperhidrosis are less likely to seek care. Here, we explore these impacts, and disparities in care, in more detail.

THE PHARMACOLOGICAL TREATMENT AND MANAGEMENT OF HYPERHIDROSIS

INTRODUCTION

Idiopathichyperhidrosis is a dysfunctional disorder involving eccrine sweat glands and its impact on patients' daily quality of life is well-known. Unlike some years ago, when only poor effective and safe therapeutic alternatives were available, nowadays, several emerging pharmacological active substances have gained significant space as treatment options.

AREAS COVERED

The authors report on, in this narrative review, the emerging data from the literature focusing on the pharmacological treatments to draw up a drug treatments flow-chart for patients with idiopathic hyperhidrosis, taking into consideration specific differences among axillary, palmoplantar and craniofacial hyperhidrosis.

EXPERT OPINION

Idiopathic hyperhidrosis, regardless of the site of involvement, remains a functional disorder that places a significant burden on patients. After balancing efficacy against adverse events, systemic therapy, although off-label for all forms of hyperhidrosis can represent an additive therapeutic option for patients with insufficient response to topical treatment according to a step wise therapeutic approach. Until the pathophysiological mechanisms underlying hyperhidrosis are clear, and the etiological therapeutic approach become realistic, the greatest challenge in the therapeutic management of hyperhidrotic patients seems to be the search for the most convenient combination between different therapeutic modalities (topical and systemic agents, and botulinum toxins) to achieve long-term control of the disease symptoms.

Antagonist of Chrna1 prevents the pathogenesis of primary focal hyperhidrosis

Background

Primary focal hyperhidrosis (PFH) is an autonomic neurological disease in which exocrine glands are oversecreted due to autonomic dysfunction of the sympathetic nervous system. Chrna1 promotes the pathogenesis of PFH. We aimed to check if downregulating of Chrna1 by cisatracurium could alleviate the symptoms of PFH.

Methods

The effect of cisatracurium in a hyperhidrosis mice model induced by pilocarpine hydrochloride was monitored for sweat gland secretion, and ultrastructural sweat secretory granules in sweat glands were analyzed. Meanwhile, markers of hyperhidrosis were checked, and release of Bdnf and Nrg1 from sympathetic ganglia axon was tested. Furthermore, the mechanism of cisatracurium function was evaluated in vitro using HEK293 expressing Chrna1. Finally, the effect of cisatracurium was determined in the hyperhidrosis mice model with overexpression or downregulation of Chrna1.

Results

In hyperhidrosis mice, pretreatment with cisatracurium effectively inhibited sweat secretion, along with fewer particle secretion in sweat glands. The molecular markers of hyperhidrosis (Aqp5 and Cacna1c) were inhibited by cisatracurium, acetylcholine (Ach) level in serum was found decreased. Neurotrophic factors (Bdnf and Nrg1) secreted by sympathetic axon activation were also inhibited. At last, it was confirmed that cisatracurium could not alter the gene or protein expression level of Chrna1, but could block the ion channel. Overexpression of Chrna1 abolished the effect of cisatracurium on hyperhidrosis, while cisatracurium could not function more in siChrna1‐treated mice.

Conclusion

Our results suggested that pretreatment of cisatracurium could alleviate hyperhidrosis in mice, probably through blocking the ion channel function of Chrna1.

Measurement properties of patient-reported outcome measures (PROMs) in hyperhidrosis: a systematic review

PURPOSE

To critically appraise, compare and summarize the quality of all existing PROMs that have been validated in hyperhidrosis to at least some extend by applying the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology. Thereby, we aim to give a recommendation for the use of PROMs in future clinical trials in hyperhidrosis.

METHODS

We considered studies evaluating, describing or comparing measurement properties of PROMs as eligible. A systematic literature search in three big databases (MEDLINE, EMBASE and Web of Science) was performed. We assessed the methodological quality of each included study using the COSMIN Risk of Bias checklist. Furthermore, we applied predefined quality criteria for good measurement properties and finally, graded the quality of the evidence.

RESULTS

Twenty-four articles reporting on 13 patient-reported outcome measures were included. Three instruments can be further recommended for use. They showed evidence for sufficient content validity and moderate- to high-quality evidence for sufficient internal consistency. The methodological assessment showed existing evidence gaps for eight other PROMs, which therefore require further validation studies to make an adequate decision on their recommendation. The Hyperhidrosis Disease Severity Measure-Axillary (HDSM-Ax) and the short-form health survey with 36 items (SF-36) were the only questionnaires not recommended for use in patients with hyperhidrosis due to moderate- to high-quality evidence for insufficient measurement properties.

CONCLUSION

Three PROMs, the Hyperhidrosis Quality of Life Index (HidroQoL), the Hyperhidrosis Questionnaire (HQ) and the Sweating Cognitions Inventory (SCI), can be recommended for use in future clinical trials in hyperhidrosis. Results obtained with these three instruments can be seen as trustworthy. Nevertheless, further validation of all three PROMs is desirable.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020170247.

Hyperhidrosis and human leucocyte antigens in the Danish Blood Donor Study

Familial clustering of the skin disease primary hyperhidrosis suggests a genetic component to the disease. The human leucocyte antigen (HLA) is implicated in a range of diseases, including many comorbidities to hyperhidrosis. No study has investigated whether the HLA genes are involved in the pathogenesis of hyperhidrosis. We, therefore, compared HLA alleles in individuals with and without hyperhidrosis in this study of 65,000 blood donors. In this retrospective cohort study, we retrieved information on individuals with and without hyperhidrosis using self-reported questionnaires, the Danish National Patient Registry and the Danish National Prescription Registry on participants recruited to the Danish Blood Donor Study between 2010 and 2019. Association tests using logistic regression were conducted for each HLA allele corrected for sex, age, body mass index, smoking and principal components. Overall, 145 of 65,795 (0.2%) participants had hospital diagnosed hyperhidrosis. Similarly, 1,379 of 15,530 (8.9%) participants had moderate-severe self-reported hyperhidrosis, of whom 447 (2.9%) had severe self-reported hyperhidrosis. Altogether 28 participants had both hospital diagnosed and moderate-severe self-reported hyperhidrosis. Severe self-reported hyperhidrosis was associated with HLA-A*80:01 (adjusted odds ratio 26.97; 95% confidence interval 5.32-136.70; n=7; p<0.001). Moderate-severe self-reported hyperhidrosis and hospital diagnosed hyperhidrosis were not associated with any HLA. The association between hyperhidrosis and HLA-A*80:01 was based on a very small number of cases and not replicated in other patient subsets, and therefore likely a chance finding. Thus, this study suggests that genes other than the HLA are involved in the pathogenesis of hyperhidrosis.

Topical glycopyrronium tosylate in Japanese patients with primary axillary hyperhidrosis: A randomized, double-blind, vehicle-controlled study

Glycopyrronium tosylate cloth, an anticholinergic drug, has been approved for the topical treatment of primary axillary hyperhidrosis in the USA, but its effects in Japanese patients have not been previously investigated. This 4-week, randomized, double-blind, vehicle-controlled, multicenter study was conducted to evaluate the efficacy and safety of glycopyrronium tosylate cloth for primary axillary hyperhidrosis patients in Japan. Eligible patients, who were ≥9 years of age and had primary axillary hyperhidrosis ≥6 months, with gravimetrically-measured sweat production ≥50 mg/5 min, and Hyperhidrosis Disease Severity Scale ≥3 (moderate) were randomized 1:1:1 to once daily topical glycopyrronium tosylate 3.75%, 2.5%, or vehicle. Overall, 497 patients (163 in the glycopyrronium tosylate 3.75% group, 168 in the glycopyrronium tosylate 2.5% group, and 166 in the vehicle group, hereinafter in this order) were randomized. Statistically higher proportions of patients in the glycopyrronium tosylate groups achieved ≥2-point improvement in Hyperhidrosis Disease Severity Scale and ≥50% reduction in sweat production from baseline versus vehicle at week 4 (51.6%, 41.1%, and 16.4%, respectively; p < 0.001 in both cases). Higher responder rates in the glycopyrronium tosylate groups compared with the vehicle group occurred as early as week 1. The most common treatment-emergent adverse events in patients treated with glycopyrronium tosylate were photophobia, mydriasis, thirst, and dysuria. Most treatment-emergent adverse events were mild as determined by the investigators. The incidence of treatment-emergent adverse events leading to treatment modification was low in the three groups. The 4-week use of topical glycopyrronium tosylate improved the patient-reported outcome measure Hyperhidrosis Disease Severity Scale and objectively-evaluated sweat production with a favorable benefit/risk profile.

Treatment of Axillary hyperhidrosis

BACKGROUND

Axillary hyperhidrosis characterized by excessive sweating in the axillary regions is a frustrating chronic autonomic disorder leading to social embarrassment, impaired quality of life and usually associated with palmoplantar hyperhidrosis. Identifying the condition and its cause is central to the management.

AIM

The aim of this article is to discuss treatment options for axillary hyperhidrosis.

METHODS

Comprehensive literature search using PubMed and Google Scholar was performed to review relevant published articles related to diagnosis and treatment of axillary hyperhidrosis.

RESULTS

Treatment modalities for axillary hyperhydrosis vary from topical and systemic agents to injectables, newer devices and surgical measures. None except for physical measures using devices or surgery, which destroys the sweat glands to remove them, is possibly permanent and most are associated with attendant side effects.

CONCLUSION

Several treatments including medical and surgical option are available for the treatment of axillary hyperhydrosis. Patient education is important component of its management. Individualized approach of management is necessary for optimal outcome of treatment.

'Excessive sweating is not a feminine thing': A qualitative study of women's experiences suffering from primary hyperhidrosis

BACKGROUND

Primary hyperhidrosis, excessive focal sweating is a common disease equally affecting men and women. Women tend to seek care more often and assess being more affected by hyperhidrosis in their daily life. The aim of this study was to explore experiences of living with primary hyperhidros in a sample of 15 women.

METHODS

Individual, semi-structured interviews with a purposive sample of 15 women diagnosed with primary hyperhidrosis and analysed by qualitative content analysis utilising an inductive approach.

RESULTS

The analysis resulted in a theme, constantly guarding the female image, based on three categories, misfitting the feminine norms, avoiding the attention of others and passing like any woman. Primary hyperhidrosis in women disrupted the ideal feminine appearance. Wearing clothes that concealed hyperhidrosis and distancing from social gatherings, in combination with negative remarks by others, created stress and anxiety and had a negative effect on self-esteem. Women felt poorly understood by others regarding the extent of their sweating and were misunderstood in intimate situations while trying to reduce the sweat production. Choices regarding education and career opportunities were affected, since being exposed and receiving attention due to primary hyperhidrosis was unwanted. Treatment with botulinum toxin liberated women from excessive sweating and removed a social handicap they described living with.

CONCLUSION

Primary hyperhidrosis in women disrupts the feminine appearance, lowers self-esteem and hinders social interactions. Clinicians assessing primary hyperhidrosis need to be aware that women may report the impairments from primary hyperhidrosis as being more associated with body image and appearance than with functional reductions in daily life. Educating patients, providing accurate information regarding the disease via media and cooperating with patient groups are important for increasing awareness and achieving progress in care for women with primary hyperhidrosis.

Cost-of-illness study for axillary hyperhidrosis in Japan

The prevalence of primary axillary hyperhidrosis in Japan is 5.75% (males, 6.60%; females, 4.72%) in the population aged 5–64 years. No study on comprehensively evaluated direct medical costs, hygiene product costs, and productivity loss in axillary hyperhidrosis patients has been published in Japan. The aim of this study was to estimate the cost of illness for axillary hyperhidrosis in Japan by conducting a nationwide insurance claims database analysis and a cross‐sectional Web‐based survey. Among patients diagnosed with primary axillary hyperhidrosis at least once between November 2012 and October 2019, health insurance receipt data of 1447 patients were analyzed. A cross‐sectional Web‐based survey was conducted on 321 patients aged 16–59 years with axillary hyperhidrosis to calculate hygiene product costs and productivity loss using a Work Productivity and Activity Impairment questionnaire. Furthermore, nationwide estimation was performed for the hygiene product costs and productivity loss based on the number of patients estimated from the prevalence. The annual direct medical costs per axillary hyperhidrosis patient were ¥91 491 in 2016, ¥93 155 in 2017, and ¥75 036 in 2018. In all of these years, botulinum toxin type A injection accounted for approximately 90% of the total costs. The annual total cost of hygiene products per axillary hyperhidrosis patient was ¥9325. The overall work impairment (%) of working patients with axillary hyperhidrosis was 30.52%, and its monthly productivity loss was ¥120 593/patient. The activity impairment (%) of full‐time housewives with axillary hyperhidrosis was 49.05% and its monthly productivity loss was ¥176 368/patient. The annual hygiene product cost based on the nationwide estimation was ¥24.5 billion and the monthly productivity loss was ¥312 billion. The significant cost associated with axillary hyperhidrosis was clarified. If out‐of‐pocket expenses for treatments not covered by health insurance are included in the estimation, the cost will further increase.

Hyperhidrosis and the risk of being treated for skin infections

BACKGROUND

A few studies have described an increased prevalence of skin infections in individuals with hyperhidrosis compared to others. However, it remains uncertain whether hyperhidrosis is an independent risk factor for skin infections.

OBJECTIVE

To compare the risk of skin infections in individuals with and without hyperhidrosis.

METHODS

In this retrospective cohort study, data on hyperhidrosis were collected from the Danish Blood Donor Study. Blood donors included in 2010-2019 were followed from inclusion until December 2019. Data on redeemed prescriptions against skin infections were collected from the National Prescription Register. The intensity of prescription-use by hyperhidrosis status was assessed in Andersen-Gill models.

RESULTS

Overall, 4,176 (9.6%) of 43,477 blood donors had self-reported hyperhidrosis and 437 (0.34%) of 127,823 blood donors had hospital diagnosed hyperhidrosis. Self-reported hyperhidrosis was associated with the use of antibiotic prescriptions (adjusted hazard ratio = 1.21; 95% confidence interval 1.00-1.45, p = 0.047). Hospital diagnosed hyperhidrosis was associated with the use of antibiotic (adjusted hazard ratio = 1.33; 95% confidence interval 1.03-1.68, p = 0.028) and topical antifungal prescriptions (adjusted hazard ratio = 1.43; 95% confidence interval 1.04-1.97, p = 0.027).

CONCLUSIONS

Hyperhidrosis is associated with the use of prescriptions for antibiotics and topical antifungals. This suggests a clinically relevant association between hyperhidrosis and skin infections.

Evaluation of the serum magnesium and vitamin D levels and the risk of anxiety in primary hyperhidrosis

BACKGROUND

Excessive sweating is considered primary hyperhidrosis if it is triggered by emotional states without any thermogenic or other underlying disease from the eccrine glands. This may be due to dysfunction in the autonomic nervous system.

AIMS

To investigate the relationship between Vitamin D and Mg deficiency and the risk of anxiety and depression in patients with primary hyperhidrosis.

PATIENTS/METHODS

This cross-sectional, case-control study was conducted between July and October 2019. 49 primary hyperhidrosis patients in Group I and 47 age and gender matched healthy individuals in Group II were included in the study.

RESULTS

The mean 25 (OH) D and Mg levels in Group I were statistically significantly lower than in Group II (p < 0.001 and p = 0.002, respectively). Statistically significant differences were found between the groups in terms of anxiety and depression (p < 0.001 and p = 0.033, respectively). There was no significant relationship between the HADS-A / HADS-D scores and the severity of primary hyperhidrosis (r = -0.131, p = 0.096; correlation coefficient = 0.232, p = 0.447). However, a significant correlation was observed between HADS-A scores and serum Mg levels (r = -0.439, p = 0.007).

CONCLUSION

Anxiety and depression are common in patients with primary hyperhidrosis. As shown in this study, both anxiety and depression can be seen with low Mg levels in patients with primary hyperhidrosis. This could possibly be related to the pathological mechanism involving Vitamin D and Mg, which determines the common pathway affecting primary hyperhidrosis and anxiety/depression.

Hyperhidrosis and Aesthetics

When one considers the avalanche of new indications and uses for botulinum toxins, it is truly surprising that this has all happened in such a short time. And the safety and dependability of these products are profound, when used appropriately. There is still much to be discovered about the potential of this agent when you contemplate the profound non-cosmetic benefits reported by clinicians and scientists from around the world. The mechanism of action has been studied in depth, and yet the benefits appreciated by people with chronic migraine or major depressive disorder, for instance, are unlikely to be explained by our current mechanistic understanding. Given that these toxins control acetylcholine at the motor end plates, and given that acetylcholine is central to practically every cell in the body, it will not be surprising to find that botulinum toxin researchers will be enjoying many decades of fruitful studies. The advent of the non-surgical aesthetic physician has helped push the clinical utilization of botulinum toxins well beyond its original adoption by oculoplastic surgeons in their patients with blepharospasm. We can expect that the next edition of this book to have a dozen or more new indications which will surprise us all.

Cost-effectiveness of topical glycopyrronium tosylate for the treatment of primary axillary hyperhidrosis

AIMS

Primary axillary hyperhidrosis (PAHH) is a condition characterized by excessive sweating that negatively impacts health-related quality of life, with significant psychological and social impacts. Glycopyrronium tosylate (GT) is a topical anticholinergic approved in the United States for treatment of PAHH in patients 9 years of age and older. Our objective was to assess the cost-effectiveness of GT as first-line topical therapy compared to topical aluminum chloride from a United States commercial perspective.

MATERIALS AND METHODS

A Markov model was developed consisting of four health states based on the Hyperhidrosis Disease Severity Scale (HDSS) over a time horizon of 5 years with discount rates of 3% for both costs and outcomes. Transitions between health states were driven by HDSS response, defined as an improvement of ≥2 points. Non-responders and those who discontinue could switch to later line treatments or no treatment. Health utility scores were based on HDSS scores, supported by published literature.

RESULTS

Over 5 years, GT yielded 0.12 greater QALYs and 0.93 greater LYs with response compared to treatment with prescription aluminum chloride at an incremental cost of $10,584. Relative to prescription aluminum chloride, GT resulted in an incremental cost-effectiveness ratio (ICER) of $87,238 per QALY gained, $11,349 per LY with response. The ICER fell below $100,000 for 66% of probabilistic sensitivity analysis simulations and below $150,000 for 82% of simulations.

LIMITATIONS

This analysis represents a simplified scenario of a hypothetical PAHH patient. Due to sparse data, assumptions were required for treatment patterns, efficacy, and persistence.

CONCLUSION

Based on the analysis of incremental cost per QALY gained, GT may be cost-effective relative to prescription aluminum chloride at commonly accepted willingness to pay thresholds.

A systematic evidence-based review of treatments for primary hyperhidrosis

Objective

Hyperhidrosis (excessive sweating) is associated with significant quality-of-life burden yet is often undertreated. With limited FDA-approved treatments, health care providers must determine optimal treatment among approved and off-label options. Key objectives of this review were to reassess, update, and expand a previous systematic review of commonly used treatment options for primary hyperhidrosis, including consideration of aluminum and zirconium compounds.

Methods

We performed a qualitative systematic review of efficacy, health-related quality of life, satisfaction, and safety of interventions, replicating and expanding the strategy outlined in a previous systematic review, with the addition of studies utilizing a within-patient design. We performed a critical appraisal of identified studies to determine risk of bias (RoB) and strength of evidence (SOE).

Results

A total of 32 studies were eligible for critical appraisal. Only three studies - two clinical trials of glycopyrronium cloth (2.4%) and one trial of botulinum toxin A injections in axillary hyperhidrosis were rated as "low" RoB; both had SOE ratings of "moderate" for use in axillary hyperhidrosis - the highest rating included in this review.

Conclusions

Optimal treatment choice depends on several factors, including understanding the quality of evidence regarding each treatment's efficacy and safety (considerations of convenience and cost are beyond the scope of this review). In hyperhidrosis, as in other clinical conditions, treatment decisions should be patient centered. At this time, because of the quality of evidence, only imprecise estimates of effect are possible for hyperhidrosis treatments included in this review, and statements about comparative effectiveness are not possible.

[Hyperhidrosis from diagnosis to management]

Hyperhidrosis is defined as uncontrollable, excessive and unpredictable sweating that exceeds the needs related to thermoregulation. It preferentially affects axillary, palms, soles and face but can affect any part of the body. This ostensibly benign symptom can have a major negative impact on quality of life sometimes leading to isolation and depression. Moreover, in some cases hyperhidrosis can be secondary to an underlying pathology sometimes malignant which must be identified quickly. Consequently, each doctor should be able to develop a diagnostic and therapeutic approach for this relatively frequent and probably underdiagnosed and undertreated reason for consultation. In this review, we focus on diagnosis hyperhidrosis and its management.

The Meaning of Living for Men Suffering From Primary Hyperhidrosis

Primary hyperhidrosis means excessive focal sweating and it has a negative effect on the mental health of those affected. Although there is no gender difference regarding the prevalence of the disease, men are less likely to seek help for this condition. The aim of this study was to explore the meaning of living with primary hyperhidrosis in men. Interviews with 15 men, selected by purposive sampling, were performed at Umeå University Hospital in Sweden between June 2016 and October 2017, and analyzed using qualitative content analysis technique according to Graneheim and Lundman (2004). This study found one theme, namely, to be captured in a filthy body, based on the categories: surrender to the condition reluctantly; prepare for a sweat attack; withdraw from close contacts; and worry about others' perceptions. The theme describes men living with hyperhidrosis feeling filthy while they struggle to control or hide the excessive sweating. Insufficient understanding from others and being reminded from the sweating is stressful and results in a sense of captivity. Interpreting the result, we conclude that the disease could stigmatize the individual, which has a negative effect on mental health and the will to seek help. Meanwhile, providing information about the disease early, as in schools, could increase the willingness of men to seek medical help. The results of this study also reinforce quantitative studies reporting the negative effects of primary hyperhidrosis on mental health.

Treatment Patterns, Depression, and Anxiety Among US Patients Diagnosed with Hyperhidrosis: A Retrospective Cohort Study

Introduction

Hyperhidrosis is associated with social and emotional stress due to limitations on health-related quality of life. This study examined real-world treatment patterns and concomitant depression and/or anxiety in patients with hyperhidrosis.

Methods

Commercial health plan members in the US with ≥ 2 hyperhidrosis diagnosis codes and/or antiperspirant prescription claims were identified from January 2010 through November 2017. A control cohort (CC) of patients without hyperhidrosis was matched to the hyperhidrosis cohort on demographic characteristics. Depression and/or anxiety were identified by ≥ 1 relevant diagnosis code or pharmacy claim. A multivariable logistic regression model estimated odds of treatment in the hyperhidrosis cohort, and depression/anxiety in the hyperhidrosis cohort and CC, adjusting for patient characteristics.

Results

A total of 44,484 patients with hyperhidrosis were identified, of whom 58.5% were female, with a mean (± standard deviation) age of 36.5 ± 16.5 years (83.5% ≥ 18 years). A small majority of patients (51.6%, 0.69/person-year) received treatment with prescription antiperspirants. Post-index oral systemic therapies, medical procedures, and surgical options were uncommon. At 12 months post-index, 48.4% of the sample had not filled a prescription for extra- or prescription-strength antiperspirants. Compared with the CC (n = 137,451), a higher percentage of patients with hyperhidrosis had depression or anxiety reported during follow-up (41.1 vs. 28.2%, p < 0.001); this corresponded to higher adjusted odds of depression/anxiety in patients with hyperhidrosis [odds ratio (OR) 1.76, 95% confidence interval (CI) 1.72–1.80, p < 0.001]. Baseline depression and/or anxiety were associated with lower odds of receiving hyperhidrosis treatment (OR 0.77, 95% CI 0.73–0.80), as was increasing age and male gender. Patients with hyperhidrosis also had more frequent incident depression/anxiety during follow-up (18.2 vs. 10.6%, p < 0.001).

Conclusion

In this real-world analysis, hyperhidrosis was associated with increased odds of depression and/or anxiety. However, relatively low percentages of patients received prescription topical or oral treatments or underwent surgery, suggesting that tolerability, efficacy, and provider awareness may be limiting factors in the effective treatment of hyperhidrosis.

Electronic supplementary material

The online version of this article (10.1007/s13555-020-00439-y) contains supplementary material, which is available to authorized users.

Hyperhidrosis Quality of Life Index (HidroQoL©): further validation and clinical application in patients with axillary hyperhidrosis using data from a phase III randomized controlled trial

BACKGROUND

The Hyperhidrosis Quality of Life Index (HidroQoL©) is a validated patient-reported outcome measure capturing the quality of life of people affected by hyperhidrosis.

OBJECTIVES

We aimed to extend the validity evidence to physician-confirmed diagnosis of primary axillary hyperhidrosis.

METHODS

Data from a phase III randomized placebo-controlled clinical trial were used (n = 171). Confirmatory factor analysis was carried out to confirm the a priori two-factor structure of the HidroQoL. Internal consistency was assessed using Cronbach's α. Intraclass correlation coefficients (ICCs) were calculated to evaluate test-retest reliability after days -7 to -4. Convergent validity was assessed using correlations with the Dermatology Life Quality Index (DLQI), the Hyperhidrosis Disease Severity Scale (HDSS) and gravimetric sweat production. Known groups were analysed to evaluate discriminative validity. Responsiveness after 29 days was assessed and minimal important difference (MID) values were calculated using both anchor- and distribution-based approaches. All analyses were carried out for total HidroQoL and its two domains.

RESULTS

The two-factor structure of the HidroQoL was confirmed. Internal consistency and test-retest reliability were strong (Cronbach's α 0·81-0·90; ICCs 0·89-0·93). Correlations with other outcome measures were in line with a priori hypotheses. The HidroQoL discriminated between different severity groups (P ≤ 0·001) and showed sensitivity to change towards improvement (P < 0·001). An MID value of 4 is proposed for the total scale.

CONCLUSIONS

This study supports excellent measurement properties including clinical applicability of the HidroQoL in primary axillary hyperhidrosis and suggests a MID of 4 be applied to clinical trial data.

Hyperhidrosis Prevalence: A Disease Underreported by Patients and Underdiagnosed by Physicians

BACKGROUND

Hyperhidrosis (HH) is a disorder characterized by excessive sweating beyond required for normal thermoregulation, as a result of the excessive functioning of the sudomotor sweat control system. HH is broadly classified into 2 categories: primary HH and secondary. Our aim was to study the prevalence of HH in patients attending dermatological outpatients.

METHODS

Randomly selected 832 attendees of dermatology outpatient department were requested to fill out a questionnaire for their presenting concerns to attend, the demography information (age, gender, and occupation), and presence of excessive visible sweating symptoms after the informed, written, and understood consent. This questionnaire was then evaluated by the researchers. And those who had a history of excessive sweating were evaluated in detail about HH by another questionnaire.

RESULTS

The overall prevalence of HH was 17.9% (149/832), whereas only self-reported prevalence was 10.2% (85/832) in the dermatology outpatients. Of 149 patients, 110 (73.8%) were of primary HH followed by 39 (26.2%) of secondary HH.

CONCLUSION

This study showed a higher prevalence of HH in the attendees of dermatology outpatients of a tertiary care center but estimates that this disease affects a much larger proportion of individuals in the Nepalese population.

Development and validation of the Axillary Sweating Daily Diary: a patient-reported outcome measure to assess axillary sweating severity

Background

Hyperhidrosis is estimated to affect ~ 4.8% of the US population, and most patients experience a negative psychological impact. Here, we describe development and psychometric evaluation of a patient-reported outcome (PRO) measure to assess severity of axillary hyperhidrosis in clinical trials that meets current U.S. regulatory standards to support product approvals.

Methods

Three rounds of hybrid concept-elicitation/cognitive-debriefing qualitative interviews were conducted in adults with clinician-diagnosed primary axillary hyperhidrosis, followed by similar interviews in children/adolescents. The draft measure included diary items for presence, severity, impact and bothersomeness (basis of the Axillary Sweating Daily Diary [ASDD]), exploratory weekly impact items, and a single-item Patient Global Impression of Change (PGIC). Phase 2 (adults only) and phase 3 (adults and children ≥9 years) clinical trial data were utilized to evaluate measurement properties of the resulting draft measure: floor/ceiling effects, nonresponse bias, test-retest reliability, construct validity, and responsiveness were assessed. The primary concept of interest was axillary sweating severity (ASDD Item 2); however, additional supportive concepts were explored to allow for development of a comprehensive hyperhidrosis measure.

Results

Twenty-nine patient interviews were conducted (N = 21 adult and N = 8 children/adolescents), resulting in the ASDD (4 items, patients ≥16y) and child-specific ASDD-C (2 items ≥9y to <16y), as well as 6 Weekly Impact items and the PGIC (patients ≥16y). No floor/ceiling effects or response biases were identified. Consistency between hypothesized and observed correlation patterns between ASDD/ASDD-C items and other efficacy measures supported construct validity. Intraclass correlation coefficients supported test-retest reliability (0.91–0.93; Item 2). Large effect sizes (− 2.2 to − 2.4) demonstrated that the ASDD/ASDD-C Item 2 could detect changes in hyperhidrosis severity, supporting the measure’s responsiveness. Patients perceiving a moderate improvement in symptoms on the PGIC experienced an average 3.8-point improvement on ASDD axillary sweating severity (Item 2); thus, a 4-point responder threshold was defined as a clinically meaningful change.

Conclusions

Qualitative and quantitative evidence support the reliability and validity of the ASDD/ASDD-C and its use in the clinical evaluation of axillary hyperhidrosis treatments. Further evaluation of this measure in future research studies is warranted to demonstrate consistent performance across different axillary hyperhidrosis populations and in different study contexts.

Endoscopic thoracic sympathectomy for primary focal hyperhidrosis: impact on psycho-social symptomatology and psychotropic medication use

OBJECTIVES

The tendency for patients with primary focal hyperhidrosis (PFH), characterized by excessive sweating, to experience psycho-social deficits is well documented. In addition, although endoscopic thoracic sympathectomy (ETS) effectively corrects PFH, its role in the psycho-social management of these patients remains unclear. Here, we examined changes in psychiatric symptomatology and psychotropic medication usage in PFH patients following ETS.

METHODS

In total, 106 PFH patients underwent ETS and were compared against 213 matched controls. Information on psychiatric diagnosis and prescription was obtained through a retrospective chart review. Prospectively, PFH patients completed Hyperhidrosis Impact Questionnaires, Leibowitz Social Anxiety Scales and Center for Epidemiological Studies Depression Scales to evaluate pre- and postoperative quality-of-life and psycho-social impairment.

RESULTS

A significantly greater proportion of PFH patients had been prescribed psychotropic medication (37.7%) compared to controls (14.1%) despite no differences in the proportion of psychiatric diagnoses. Following ETS, 52.5% of the PFH patients who were using psychotropic medications reduced their prescription regimen, compared to only 10% of control patients (P < 0.01). Additionally, scores improved dramatically in each Hyperhidrosis Impact Questionnaires category, and in both the Leibowitz Social Anxiety Scales and Center for Epidemiological Studies Depression Scales (P < 0.01).

CONCLUSIONS

We demonstrate that in over half of PFH patients, psychotropic medication usage was discontinued after ETS, which is consistent with our findings on postoperative improvements in Hyperhidrosis Impact Questionnaires, Leibowitz Social Anxiety Scales and Center for Epidemiological Studies Depression Scales scores. Furthermore, our findings suggest that a considerable proportion of PFH patients who experience psychopathology may be doing so secondary to excessive sweating. Thus, improved awareness or recognition of these associations in the diagnosis and management of PFH patients is warranted.

Topical Glycopyrronium Tosylate for the Treatment of Primary Axillary Hyperhidrosis: Patient-Reported Outcomes from the ATMOS-1 and ATMOS-2 Phase III Randomized Controlled Trials

BACKGROUND

Glycopyrronium tosylate (GT) is a topical anticholinergic approved in the USA for primary axillary hyperhidrosis in patients aged ≥ 9 years. GT was evaluated for primary axillary hyperhidrosis in replicate, randomized, double-blind, vehicle-controlled, phase III trials. GT reduced sweating severity and production versus vehicle and was generally well tolerated.

OBJECTIVE

Our objective was to evaluate patient-reported outcomes (PROs) from these trials.

METHODS

Patients aged ≥ 9 years with primary axillary hyperhidrosis ≥ 6 months, gravimetrically measured sweat production ≥ 50 mg/5 min in each axilla, Axillary Sweating Daily Diary (ASDD) Item 2 severity score ≥ 4, and Hyperhidrosis Disease Severity Scale (HDSS) score ≥ 3 were randomized 2:1 to GT 3.75% or vehicle applied once daily to each axilla for 4 weeks. The 4-item ASDD, 6 Weekly Impact (WI) items, Patient Global Impression of Change (PGIC), HDSS, and Dermatology Life Quality Index (DLQI) were utilized.

RESULTS

In the pooled population, 463 patients were randomized to GT and 234 to vehicle; 426 (92.0%) and 225 (96.2%) completed the trials. At baseline, most patients considered their axillary sweating to be at least moderate in severity, impact, and bothersomeness (ASDD items 2, 3, and 4, respectively). Improvement was substantially greater for GT than for vehicle at every study week, and, at week 4, ASDD scores improved from baseline by 62.6 versus 34.0% (severity), 65.5 versus 40.3% (impact), and 65.4 versus 39.0% (bothersomeness). Improvements favoring GT versus vehicle also occurred for WI items, PGIC, HDSS, and DLQI.

CONCLUSIONS

PRO results demonstrated that GT reduced the disease burden of primary axillary hyperhidrosis.

TRIAL REGISTRATION

Clinicaltrials.gov; ATMOS-1 (NCT02530281), ATMOS-2 (NCT02530294).

Combination of topical agents and oxybutynin as a therapeutic modality for patients with both osmidrosis and hyperhidrosis

INTRODUCTION

The association of osmidrosis and hyperhidrosis often causes emotional and social problems that may impair the patients' quality of life. The purpose of our study was to analyze the therapeutic results of oxybutynin and topical agents in 89 patients with both osmidrosis and hyperhidrosis.

METHOD

We conducted an observational study at two specialized centers of hyperhidrosis between April 2007 and August 2013. Eighty-nine (89) patients with both osmidrosis and hyperhidrosis were treated with oxybutynin and topical agents. Patients were evaluated before treatment and at 3 and 6 weeks after treatment started, by using the Quality of Life Questionnaire and the Sweating Evolution Scale.

RESULTS

Before treatment, 98% of the patients presented with poor or very poor quality of life. After six weeks of treatment, 70% stated their quality of life as being slightly better or much better (p<0.001) and nearly 70% of the patients experienced a moderate or great improvement in sweating and malodor. Improvement in osmidrosis was significantly greater when the axillary region was the first most disturbing site of hyperhidrosis.

CONCLUSION

There was a significant improvement in quality of life and a reduction in sweating and malodor after six weeks of treatment with topical agents and oxybutynin in patients with both hyperhidrosis and osmidrosis. Therefore, clinical treatment should be considered before invasive techniques.

Hyperhidrosis - Sweating Sites Matter: Quality of Life in Primary Hyperhidrosis according to the Sweating Sites Measured by SF-36

BACKGROUND

Primary hyperhidrosis has negative impacts on quality of life. The aim of this study was to investigate whether the impacts of primary hyperhidrosis on quality of life are different depending on the localisation of the sweating.

METHOD

We compiled background data, Hyperhidrosis Disease Severity Scale (HDSS), and Short-Form Health Survey (SF-36) post hoc results from 2 previous studies. Cases who described only 1 site as their most problematic area of sweating were included (n = 160/188) while individuals with multifocal primary sites of hyperhidrosis were excluded (n = 28/188).

RESULTS

Individuals included were 11-62 years old with a mean age of 30.2 ± 10.4 years, and axillary hyperhidrosis (65.6%) was the most common type of hyperhidrosis. Comorbidities were more common when hyperhidrosis was reported in other than the axillary, palmar, and plantar regions. Excluding comorbidities showed the lowest SF-36 mental component summary scores for axillary (41.6 ± 11.6), palmar (40.0 ± 9.4), and plantar hyperhidrosis (41.1 ± 13.7). The HDSS showed the highest proportion of severe cases in axillary (60.6%) and palmar (51.5%) hyperhidrosis (p < 0.01) while mild cases were more often observed in plantar (60%), facial (83.3%), and other sites (85.7%) in primary hyperhidrosis (p < 0.01).

CONCLUSION

Our results indicate that impairments in quality of life can be different depending on the manifestation of primary hyperhidrosis on the body. This can have an influence on how patients with hyperhidrosis could be prioritised in health care. Subgroup samples affected by facial hyperhidrosis and other sites of primary hyperhidrosis were however small, and more research is required to verify our findings.

The impact of hyperhidrosis on patients' daily life and quality of life: a qualitative investigation

BACKGROUND

An understanding of the daily life impacts of hyperhidrosis and how patients deal with them, based on qualitative research, is lacking. This study investigated the impact of hyperhidrosis on the daily life of patients using a mix of qualitative research methods.

METHODS

Participants were recruited through hyperhidrosis patient support groups such as the Hyperhidrosis Support Group UK. Data were collected using focus groups, interviews and online surveys. A grounded theory approach was used in the analysis of data transcripts. Data were collected from 71 participants, out of an initial 100 individuals recruited.

RESULTS

Seventeen major themes capturing the impacts of hyperhidrosis were identified; these covered all areas of life including daily life, psychological well-being, social life, professional /school life, dealing with hyperhidrosis, unmet health care needs and physical impact.

CONCLUSIONS

Psychosocial impacts are central to the overall impacts of hyperhidrosis, cutting across and underlying the limitations experienced in other areas of life.

[Dermatological diseases and their importance for psychiatry]

The relationship between skin and psychiatric disorders is not an uncommon occurrence in the clinical practice; however, there are only a few systematic studies and in addition knowledge about the neurobiological and immunological mechanisms is lacking. Impairments and disorders of the skin are often an (early) sign of a psychiatric disorder. In the sense of true psychosomatics, psychiatrists should also be aware of this relationship as far as possible. This review article focuses on the most important dermatological diagnoses in relation to the respective psychiatric comorbidities and presents the most important aspects of epidemiology, symptomatology, pathophysiology and treatment options.

Tap water iontophoresis in the treatment of pediatric hyperhidrosis

AIM OF THE STUDY

The treatment options for localized hyperhidrosis include antiperspirants, anticholinergics, iontophoresis, botulinum toxin and surgery. Tap water iontophoresis (TWI) involves immersing the affected area in tap water and passing a small electrical current through the area. Our aim was to assess the success of this therapy in a pediatric cohort.

METHODS

Retrospective case note review of all patients younger than 18years who underwent TWI between 2002 and 2015. Demographic data, number of treatment sessions, side effects and overall success were analyzed. Individuals undergo 7 treatments over 4weeks. A positive outcome was determined as an improvement in symptoms. Pre- and posttreatment hyperhidrosis disease severity scale (HDSS) was measured. Data are presented as mean (range). Statistical analysis was by paired t-test. A P value of <0.05 was regarded as significant.

RESULTS

There were 43 patients (30 females) with a mean age of 15 (8-17) years. Palmar and/or plantar hyperhidrosis (PPH) was present in 39/43 (91%) patients. Axillary hyperhidrosis (AH) was present in 19/43 (44%) patients. All patients (with the exception of one) underwent 7 sessions (5-7). Side effects included paresthesia (88%), pruritus (26%), pain (26%), erythema (14%), dryness (12%) as well as vesicle formation and abrasions in one patient (2%). A positive outcome was found in 84% (36/43) of patients. There was a significant reduction in mean HDSS (pre 3.5 vs. post 2; P=0.0001).

CONCLUSION

TWI is a safe and effective modality of treatment for both PPH and AH in the pediatric population, with minimal side effects. Pediatric surgeons should offer this treatment option before considering more invasive surgical procedures.

LEVEL OF EVIDENCE

IV: Retrospective study.